Study: Supportive care can improve quality of life for people with metastatic breast cancer

IN-DEPTH REVIEW OF RESEARCH

Study background:

Metastatic breast cancer accounts for 6% of all breast cancer cases at diagnosis. Additionally, approximately 30% of women diagnosed at earlier stages will have breast cancer progress to metastatic or stage IV disease.

Women with metastatic breast cancer have unique needs compared to those with earlier stages of breast cancer. There are different treatments considerations, palliative concerns as well as distinct psychological, social, financial, and family issues. Primary care or nursing providers often lack time or overview needed to support all aspect of patient needs. There is a growing role for patient nurse navigators (PNN) who may be oncology nurses or social workers or community members who are versed in their field. Prior work has shown that PNNs have been beneficial in coordinating care for patients with other types of cancer or early stages of cancer. The usefulness of PNNs for patients with metastatic breast cancer has not been previously tested.

Researchers of this study wanted to know:

whether a program for supportive care for metastatic breast cancer patients improves the health care experience.

Populations looked at in this study:

Participants were patients at a Western Pennsylvania cancer care facility. Chart reviews were done for all women who came through the clinic between August and October 2016, 3 months prior to start of the Metastatic Breast Cancer - Support Education and Advocacy (MBC-SEA) program (186 women), and again 3 months after the program began February to April 2017 (196 women). Women whose charts were reviewed both before and after the MBC-SEA program began were included in the study (118 women). On average, the women in the study were 50-69 years of age, had MBC for 3 years, were receiving hormonal or targeted treatment, and were estrogen receptor-positive.

Study design:

The MBC-SEA program was developed to connect metastatic breast cancer patients with existing supportive and educational services. A patient nurse navigator (PNN) performed weekly chart reviews for each patient to evaluate treatment status, symptoms, distress, social and financial needs, clinical trial eligibility and counseling needs. The PNN then coordinated supportive services with a collaborative group including practice nurses, palliative care nurses, social workers and the clinic team coordinated scheduling and sent clinical reminders for follow up. This allowed targeted, individualize care plans to be developed for each patient.

Data on 118 women with metastatic breast cancer were evaluated before and after the MBC-SEA program was started.

Study findings:  

Patient reported statistically significant improvements in outcomes using the following:

• The Magee Women's cancer service (MWCS PROcis) symptom inventory evaluates patient-reported outcomes including fatigue, nausea, sleep distress, shortness of breath, dry mouth, sadness, vomiting, numbness or weakness in limbs on a scale of 1 to 10 for each symptom.
  • Participants reported fewer or lessened symptoms on the Magee Women's cancer service questionnaire. Scores decreased on average 1.35 (on a 10-point scale) after the MBC-SEA intervention compared to before the intervention.
     
• The Generalized Anxiety Disorder (GAD) evaluation measures feelings of nervousness, anxiety, worry, restlessness, irritability and fear.
  • Participants reported decreased anxiety and distress on a Generalized Anxiety Disorder evaluation with scores decreasing on average 1.56 ( on a 10-point scale) after the MBC-SEA intervention compared to before the intervention.
     
• A visual analog scale was used to determine participants overall sense of well-being.
  • Participants reported greater overall sense of well-being after the MBC-SEA intervention. Increasing on average 0.7 ( on a 10-point scale) after the MBC-SEA intervention compared to before the intervention.
     
• There were more referrals for social work and palliative care (indicating patients were connected with needed services).
  • Prior to the MBC-SEA program there were 13 referrals for social work and 14 referrals for palliative care. After the MBC-SEA program began, there were 44 referrals for social work and 31 referrals for palliative care.
     

Clinical trial referrals did not increase.

Limitations:

This study has a number of limitations:

• A major limitation is the size of the study. The intervention included only 118 women with metastatic breast cancer. This is a relatively small sample size. This sample size was large enough for the researchers to show statistically significant differences in symptoms, anxiety, overall well-being and referral rates. However, the number of patients is too small to say anything about age, hormone-receptor status, treatment type or other clinical differences. The participants in this study were mostly 50-69 years old, ER+, in hormonal or targeted treatment and from one clinic. Larger studies would be needed to see if these interventions are useful across a broader demographic of patients.
   
• Another major limitation of this study is that there is no true control group. Responses of patients after the beginning of the MBC-SEA program were compared to their own responses before the MBC-SEA program began. There were no patients that received the prior standard of care during the same time. Because this program is in place and ongoing, it is not possible to reevaluate this program intervention in this location. However, similar programs could be tested in other places.
   
• This study was conducted at a single cancer clinic in Western Pennsylvania. It is unclear if this intervention program would be similarly effective in other geographic regions given differences in the population of and underlying support services available in different places.
   
• The patients that were evaluated in this study were patients that were seen in both of two specific 3-month windows. These patients may not be representative of MBC patients as a whole.
   
• The study researchers point out that the study is limited in that the clinic did not have a standardized threshold for some of the evaluated measure (e.g. distress) that would trigger the referral process. Because of this, there may be some variability in when patients were referred for psychosocial consultations. However, standardized thresholds would be expected to improve differences before and after the intervention.

Conclusions:

The researchers conclude that support intervention programs like the MBC-SEA can improve care and quality of life for metastatic breast cancer patients. Additional data on a larger group of patients in other regions would be useful to determine how generalizable these results are.

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Posted 8/21/19

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